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Frequently Asked Questions about Esketamine

“I have Bi Polar Type 2 (not officially diagnosed as my GP had already started my treatment on mood stabiliser Olanzapine) I am diagnosed as having Major depression, I’m on a SNRI Venlafaxine, also diagnosed with very mild BPD, and generalised anxiety disorder, I have taken street ketamine before and use once a week, it seems to work on my suicidal thoughts very well, I’d like to investigate how I get it prescribed legally please, thanks hope to hear from you, Kind regards…”

Hi, thanks for getting in contact with us, as a medical team we are looking to specialise further in esketamine if you have any further questions please do not hesitate to contact us. As for the specifics of your enquiry…

In your first sentence, you mentioned that you have been “not officially diagnosed” as “Bi Polar“. The current license (Aug 2020) of Spravato mentions “the medicine should specifically be used in the treatment of Treatment-Resistant Major Depression” and does not mention bi polar until later in the document where it specifies: “Spravato should be used with caution”… “in patients with a history of mania or bipolar disorder“. This does not mean it cannot be used in bi-polar, only the psychiatrist that may prescribe Spravato will need to keep this in mind as other complications may arise.

You then mention you have been officially diagnosed with Major Depressive disorder, but you do not mention whether this is classified as Treatment-Resistant of not. Again, for you to meet the requirements of the license you will have to have been diagnosed with Treatment-Resistant Major Depression (TRMD). But what defines Treatment Resistant? Unfortunately, this term differs dependent on which psychiatrist you use. The most simplistic definition of treatment resistance “is the failure to achieve and sustain euthymia (normal, tranquil mental state) with adequate antidepressant treatment.” ² Whether the “treatment” includes ECT, or different types of medicines is unspecified. Lastly, please be aware that accessing “street ketamine” has its own associated risks we highly recommend that you first try access the medicine from a licensed prescriber and subsequently get access to the medicine via a verified supply chain.

To summarise, to be prescribed esketamine you will need to meet the following criteria¹:

  • taking an SNRI (which you already meet as you are taking venlafaxine)
  • diagnosed by a licensed doctor as suffering from “treatment-resistant Major Depressive Disorder”. (it doesn’t seem you have this yet).
  • unresponsive to at least two different treatments with antidepressants in the current moderate-to-severe depressive episode. (this is the definition of treatment-resistant within the license, however, in your enquiry, you do not mention how many previous treatments you have tried) ?

“I would like to try the ketamine nasal spray. I’ve tried six different anti depressants over the years and currently taking duloxetine, but nothing helps..only makes me tired and just as depressed. I’ve tried homeopathy and acupuncture also. Hoping to try this medication.”

As per the current license¹ you potentially meet the definition of treatment-resistant major depression (TRMD), however, as above this definition is at the psychiatrist’s discretion. It doesn’t seem you are taking an SNRI currently.

What is the mechanism behing how ketamine works?

As far as the most recent research has discovered it seems ketamine operates on a receptor level as NMDA antagonist and regulate the availability of the neurotransmitter glutamate in the brain. The antidepressant effect appears to be mediated by downstream signal effects of AMPA receptors. A variety of other receptors are targeted and contribute to the acute and ongoing effects of treatment.

What is the clinical ketamin experience like in practice?

Prior to treatment:

– Patients are expected to abstain from all substance use for a period of 48 hours; including alcohol tobacco, cannabis, illicit substances.

– In certain instance, a urine toxicology screen maybe required prior to treatment, including on the day of treatment

– No dietary food or opaque drink intake for least 4 hours prior treatment.

– One cup of clear fluids is permitted between 4 and 2 hours prior.

– Strictly NO intake is allowed for the 2 hours leading up to the appointment.

– Hold medication that may raise blood pressure – i.e. stimulants

  • Continue on anti-hypertension and diabetic medication, with dose of adjustment of insulin based on dietary intake adjustment.

Standard course:

Preparation:

– Medical evaluation of readiness for treatment including Informed Consent.

– Blood pressure screening.

– Confirmation that an after-care/support person is available for pick-up from office and accompany you for a further 4 hours after discharge.

– Completion of K10 screening forms

Dosing: Onset 15-45minutes

– Ketamine, initial dose based on 0.5mg/kg lean body mass

– Subjective evaluation of patient capacity to tolerate the dissociative state.

Sedated state: 45-90 minutes:

Generally restful, mostly non-verbal, supported by soothing music and eye shade to minimize light effect(please bring with you)

– Patient will typically experience a heaviness in the physical body, possibly with the changes in sensation, followed by a separation from the usual state of cognitive processing, such that verbal expression may either become limited.

– Patients will remain rousable to an alert and interactive state and will be checked in on by verbal cue to determine if there are any concerns. Physical contact will consist of provider placement of hand on the arm or shoulder of the patient – with contact over clothing; unless there is concern for medical emergency.

– Some patients may experience unfamiliarity with this state that is disconcerting perhaps in the heaviness/floating sensation, vertigo like sensation, physical discomfort (nausea), the presentation of distressing imagination.

– During this phase of treatment blood pressure will be checked.

– Patient also consent to allow for video monitor of the experience in order to assure safety and mutually mitigate concern for behavior that may be aversive, intrusive or experienced as such by the patient in an altered state of awareness. – i.e. a gentle hand placed on the shoulder.

Integration Phase: 90-120 minutes: Opportunity for reflection and discussion

– Patient will be engaged verbally to describe the experience and potentially engage in discussion of thoughts, emotional states and physical sensations.

Disengagement from treatment

At any point in the treatment course, the patient may disengage from the defined and recommended process i.e. sit up and take off the eye shade. However, patients will not be allowed to leave the office on their own until 90 minutes after dosing of ketamine. The patient may request that the defined after-care support assume custody at any point during the treatment, with full release into care to be determined by the physician providing care / administering the dose.

Initial dosing (i.e. 0.5mg/kg ) is designed to place patients in state that is often described as a “one glass of wine effect”. Patients not exhibiting significant effects are given an option to increase the nasal spray treatment dose on the next treatment episodes to 0.75 & 1.0mg/kg.

If you are interested in submitting a question to our team, please contact us.

Reference

1. Spravato UK license accessed on 18th August 2020 via: https://www.medicines.org.uk/emc/product/10977/smpc (last updated 29 Jul 2020)

² DEFINITION AND EPIDEMIOLOGY OF TREATMENT-RESISTANT DEPRESSION, Psychiatric Clinics of North America, Volume 19, Issue 2, 1 June 1996, Pages 179-200. Accessed on 18th August 2020 via https://www.sciencedirect.com/science/article/abs/pii/S0193953X05702835

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